ATI RN
ATI Medical Surgical Proctored Exam Questions
Question 1 of 5
A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
Correct Answer: C
Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.
Question 2 of 5
A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?
Correct Answer: C
Rationale: The correct answer is C: Report any signs of bruising or bleeding to your healthcare provider. This instruction is crucial because warfarin can increase the risk of bleeding, especially in clients with a history of gastrointestinal bleeding. Reporting any signs of bruising or bleeding promptly allows for timely intervention to prevent serious complications. A: Avoiding foods high in vitamin K is not necessary, as consistent intake of vitamin K-containing foods can help maintain stable anticoagulant levels. B: Taking aspirin along with warfarin can increase the risk of bleeding and should be avoided. D: Limiting fluid intake is not directly related to the management of warfarin therapy or gastrointestinal bleeding.
Question 3 of 5
When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?
Correct Answer: D
Rationale: The correct answer is D because performing hand hygiene before and after client contact is crucial in preventing the spread of infection in pneumonia. This intervention helps in reducing the transmission of infectious agents from one client to another and from surfaces to clients. It is a fundamental infection control measure that minimizes the risk of spreading pathogens. Option A is important for treating the infection but does not directly prevent its spread. Option B is a good practice to contain respiratory secretions but may not be as effective as hand hygiene. Option C isolates the client but does not address the primary mode of transmission through contaminated hands.
Question 4 of 5
A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?
Correct Answer: C
Rationale: Step-by-step rationale: 1. COPD is characterized by airway obstruction, leading to difficulty exhaling. 2. Prolonged expiratory phase is a common finding due to air trapping. 3. This leads to hyperinflation and increased residual volume. 4. Decreased anteroposterior chest diameter is not typical in COPD. 5. Increased breath sounds and chest expansion are not common in COPD. In summary, choice C is correct because it directly relates to the pathophysiology of COPD, while the other choices are not consistent with the condition.
Question 5 of 5
A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
Correct Answer: D
Rationale: Step 1: Isoniazid (INH) can cause liver toxicity. Step 2: Regular liver function tests help monitor for liver damage. Step 3: Monitoring liver function is crucial to prevent serious complications. Step 4: Other choices are not directly related to INH's side effects. Summary: Choice D is correct as it directly addresses a potential serious side effect of INH. Choices A, B, and C are not directly relevant to the medication's side effects.